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I read with great interest the paper by Deftereos et al. (1) that was recently published in the Journal. The authors proposed a novel, promising strategy to prevent acute kidney injury by ischemic post-conditioning at the target lesion in patients with non–ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). However, nonsignificant cardioprotection was obtained using regular protocol algorithms (4 cycles × 60-s inflation/60-s deflation) in the clinical setting (2).

In addition to the cycles and time interval, accumulating evidence has suggested that several technical issues may improve cardioprotection by postconditioning, such as the balloon position for conditioning, the conditioning delay to first inflation, and the stenting technique. Thuny et al. (3) presumed that the postconditioning protocol must be performed upstream of the site of the culprit lesion to reduce microembolisms. On the other hand, the conditioning delay to first inflation has been recognized as an important determinant of reduction in infarct size (2). Prolongation of delay from 10 to 30 s to 60 s (4,5) or 10 min (6) has been indicated to result in the failure of cardioprotection by post-conditioning in animal studies. In patients undergoing PCI, post-conditioning still confers a cardioprotective effect with the delay ranging from 30 to 180 s (2) but not up to 5 min (7). In addition, the direct-stenting technique also could attenuate coronary microembolization (8) and may preserve the cardiac protection of post-conditioning in PCI (9,10). Future clinical studies concerning post-conditioning in PCI should standardize the maneuvers.

Nevertheless, these technical concerns were not reported clearly in the study by Deftereos et al. (1), which is not the same as the recent studies by Thuny et al. (3) and Tarantini et al. (11). Thus, readership would benefit more from this missing information, and I am interested to know their use in both the post-conditioning group and the control group.

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